The Babe’s Guide to Bottle Feeding

Unlike breastfeeding, we’ve all seen bottle feeding, and we all know how to do it. We’ve been surrounded by it growing up. If someone handed you a baby and a bottle you would know what to do right? Of course you would, but would you know how to do it safely?

Despite the large number of parents who use bottles in today’s society (whether those bottles contain breastmilk or formula), there are very few who have actually been taught how to bottle feed their baby in a manner that is respectful of the baby’s airway and natural feeding rhythm.

Bottle feeding may seem like a strange topic for a lactation consultant to be blogging about, but I feel it’s an important one. Traditional bottle feeding methods can cause problems for both breastfed and bottle fed babies, and all babies deserve to be fed in a respectful manner. By “traditional” bottle feeding, I mean the method of bottle feeding that most of us are used to, which is baby more or less on his back, and the bottle being tipped up to ensure there are no air bubbles.

This baby is being overwhelmed with milk and is showing clear stress signs.

Although I work with breastfeeding moms and babies, I do a lot of teaching about bottle feeding. The moms that come to me are usually having difficulty with breastfeeding, and are sometimes supplementing breastfeeding with bottles of expressed milk or formula. There are, of course, alternate methods of supplementing (supplemental nursing system, finger, syringe or cup feeding) but many moms are either already using bottles when I see them, or find that bottles are simply easier to deal with because they are familiar.

I often hear from moms who are afraid that they aren’t producing enough milk because their baby will gulp down a bottle after breastfeeding. It’s important for parents to understand that with traditional bottle feeding methods, babies have no choice but to gulp down everything in their bottle in order to protect their airway. If you hold a bottle upside down (even one with a slow flow nipple), it drips. When a baby being given a bottle swallows, the negative pressure created draws more milk into the baby’s mouth, meaning the baby has to swallow again to avoid choking. This is stressful for the baby, and babies will often display stress cues such as splayed fingers or toes, milk running out of the corner of the baby’s mouth, trying to turn their head away, or trying to push the bottle away. The picture above is a good example of this.

It’s not normal for babies to gulp down their entire feeding in a few minutes. When you watch a baby breastfeeding, you see that they drink for a while then take a little break before drinking again (with the exception perhaps of oversupply/forceful let down, which is a different situation). Breastfeeding is the biological norm for infant feeding. This means that with any other feeding method used, care should be taken to mimic breastfeeding as much as possible. I have seen traditional bottle feeding methods lead to overfeeding, spitting up, reflux, wheezing and difficulty breathing while feeding, and even feeding refusal (due to feeding being so stressful). Bottles being given to a breastfed baby can also cause problems with breastfeeding. Babies suck differently from a bottle than they do at the breast, and babies can become accustomed to the faster flow of milk from a bottle, causing them to become impatient at the breast. The tips below can help to minimize some of the problems associated with bottle feeding.

Tips for bottle feeding any baby (not just a breastfed one!)

Good positioning for bottle feeding, and a baby who is relaxed and enjoying feeding.

1. Hold your baby sitting upright, and start by placing the nipple of the bottle against your baby’s top lip. Wait for your baby to open up before putting the bottle in his mouth. Never force a bottle into a baby’s mouth.

2. Your baby should be sitting up enough that the bottle is horizontal (parallel to the floor). Tip the bottle just enough to keep the tip of the nipple filled with milk (as the bottle empties, you will have to tip the bottle up more). It’s fine if there is an air bubble at the base of the nipple as long as the tip is filled with milk. This works much better with a straight bottle rather than an angled one.

3. If you are supplementing a breastfed baby, or pumping and bottle feeding in the hopes of getting baby back to nursing, it is beneficial to let your baby suck on the nipple for a minute or two without getting anything, and then tip the bottle so your baby is getting milk. When breastfeeding, babies have to wait a minute or so for mom’s milk to let down, and they have to suck to trigger that let down. Babies who have been bottle fed sometimes get used to the immediate reward from the bottle and then are impatient at the breast and don’t want to wait for let down. By letting baby suck for a short while without getting anything from the bottle, you are mimicking the process at the breast, and it can help with the transition. There is no need to worry about your baby taking in air, one end or the other it will come back out!

4. Watch your baby’s cues. All babies, whether breast or bottle fed should be fed whenever they show signs of being hungry, and not according to any kind of schedule. During feeding, if your baby starts to show any signs of stress (splayed fingers and toes, milk spilling out of mouth, turning head away, pushing bottle away – see picture above) then your baby needs a break. Keep the bottle in your baby’s mouth, but tip the bottle so that the nipple is pointing towards the roof of the baby’s mouth. By doing this, your baby knows that the bottle is still there and will start sucking again when ready. At that point you can tip the bottle back up so that baby is again getting milk. It is frustrating for your baby if you take the bottle out of his mouth to give him a break because he doesn’t know where it has gone or if it’s coming back. If your baby is showing signs that he is done (turning head, trying to push bottle away etc), then respect those cues and end the feeding.

5. Alternate sides part way through the feeding to mimic breastfeeding and allow stimulation to both eyes and both sides of the body. This also helps to prevent the development of a side preference when feeding.

6. Find a nipple that works well for your baby. There are no black and white answers as to which bottle nipple is “best” for a breastfed baby, because all babies are different. For young babies, make sure you are using a slow flow nipple. Even with older babies a slow flow nipple may be best if your baby is struggling with the flow of milk. Don’t worry about the recommended ages on the bottle nipple packaging, watch your baby to determine what works best for them. Unfortunately, “slow flow” is not something that is standardized, and some “slow flow” nipples actually flow quite quickly, so again, watch your baby. I do not recommend the “Nuk” or orthodontic type nipples because mom’s nipples don’t look like that! (If mom’s nipples are pinched or flattened after baby feeds, it’s a sign that baby isn’t latched on properly, or some other issue is causing baby to compress the nipple). Your baby should be able to “latch” onto the base of whichever nipple you use. Some bottle nipples that are advertised as having a wide base and being “more like mom’s breast”, are so wide that baby ends up being just on the nipple, which is something to be avoided. There are some good pictures of how your baby should look when latched onto a bottle nipple on this Best for Babes post, titled How to Bottle-feed as You’d Breastfeed, and more information at the website www.breastandbottlefeeding.com.

Things to avoid:
1. Never prop a bottle. It’s a dangerous practice that is stressful for your baby.

2. Don’t bottle feed your baby while he’s swaddled. You need to be able to see your baby’s hands to watch for stress signs, and your baby needs to have his hands free to participate in feeding.

3. Don’t feed your baby with him facing away from you. Feeding is an important time for the development of social interaction in babies. Make eye contact with your baby, talk to him and enjoy the feeding as a fun interaction with your baby rather than another task to get through as quickly as possible.

4. Don’t force your baby to finish a bottle by twisting it or moving it around in baby’s mouth. Let your baby decide when he’s done. Overfeeding can lead to an uncomfortable and unhappy baby!

Safe use of formula
Along with bottle feeding, I also do a lot of teaching about safe formula preparation because many parents are not informed about the dangers of giving powdered formula to young or ill babies, and haven’t been taught how to prepare powdered formula safely.
Powdered infant formula is not a sterile product and there have been cases of powdered formula being contaminated with the bacteria E. sakazakii, which can easily be fatal for young children. Babies under the age of one year are at particular risk of infection with E. sakazakii, with the greatest risk being for those who are less than 28 days old, or who are preterm, low birth weight, or immunocompromised (have a weakened immune system). For these babies, liquid formula should be used because it is sterile.

If you are using powdered formula it is very important for it to be properly prepared in order to kill any potential bacteria. Powdered formula needs to be mixed with water that is at least than 70 degrees Celsius (boil the water and let it cool for no more than 30 minutes before mixing it with the powder). It can then be cooled to an appropriate temperature for feeding or cooled and stored in the fridge for no more than 24hrs. You can read more detailed information about the proper preparation of powdered infant formula.

If you are using liquid formula, make sure you follow the directions on the can closely. There are two types of liquid formula – ready to feed and liquid concentrate. The liquid concentrate must be mixed with the proper amount of water (as outlined on the can) before feeding. Failure to mix liquid concentrate formula with the right amount of water can have severe consequences for your baby.

Editor’s note: This post was originally published in December 2010 on the Nurtured Child blog by Fleur Bickford, RN, IBCLC, LLL. We’re so grateful that she’s allowed us to repost it and that we can share this important information here!

Fleur Bickford is a nurse, lactation consultant, and mother of two. She’s passionate about helping families discover the joys of breastfeeding, birth and parenting, and providing parents with evidence based information. She is a private practice lactation consultant in Ottawa Ontario. You can find more information about Fleur on her website, www.nurturedchild.ca.

22 Responses to The Babe’s Guide to Bottle Feeding

THANK YOU so much for posting this! I don’t know if the general public is aware, but IBCLCs, CLCs and all hospitals who participate in the Baby-Friendly Hospital initative are required to share SAFE formula preparation methods upon request. We care about mothers & babies and if a mom chooses to formula feed, she deserves good information about how to safely feed her baby. KUDOS to BfB for sharing good information about safer formula prep!!

Thank you SO much for posting this! Actually, the first paragraph is wrong for me… I wouldn’t know how to bottle feed a baby and I’ve been worried about having to do this after my baby is born next month, and my all-too-short maternity leave is over. I’ll be pumping every day, but I want my baby to still be fed respectfully & healthfully, even though it won’t be directly from the breast. I’ll have to show this to my husband, so he can learn how to best feed our baby my expressed milk.

As a Doula /CLC I was able to take an extraordinary workshop given by the New York Lactation Consultants Association, the speaker could have been this woman, I don’t remember her name, but she was an IBCLC, LLLL and a retired industrial designer.

The workshop focused on the lactation community to educate and pass along the correct way to feed with a bottle. Correct infant feeding goes a long way in having a comfortable baby and for the family to understand the baby’s feeding cues.

Very useful especially info for babies that need to switch back and forth between bottles and breast when the mother returns to work and is pumping.

All professionals working with childbearing families should know how to teach this correct bottle feeding, and pass it along. Women returning to work outside the home need help choosing the correct nipple/bottle and how to bottle feed a breastfed baby. Postpartum Doulas, CLC and IBCLC can teach this to families as they transition to a bottle.

this is SUCH a great post! I am sure it will really help a lot of people. and the info about safe preparation of powdered formula is worth it’s weight in diamonds! the information about preparation and the risks of non-sterile powdered formula are NOT included on formula. the guidelines given by the companies most often do not meet the proper guidelines as given by the WHO and as you have shared here, so many babies are at risk of possibly life-threatening G.I. infection. i hope this post is shared as widely as possible!

This is by far one of the best articles I’ve seen on bottle feeding technique. I appreciate your non-judgmental, practical tone. Wherever we stand on the subject of breast vs bottle, the fact remains that the majority of moms who work or want to spend an occasional night out at some point during a year or more of nursing are going to use bottles of expressed milk. And many others may supplement with formula. Pretending that this doesn’t happen hurts babies, which is counterproductive to breastfeeding advocacy, IMO. Too many women come to my blog asking questions about bottles and formula that should have been answered by a medical professional from the get-go, and I find it so frustrating that we are given no information about these things. You are a gem, Fleur! A wholehearted “thank you” from a pro-breastfeeding/pro-bottle-feeding/pro-baby/pro-mama mama!

This is something I teach at the WIC office on a daily basis. Few parents know how to bottle feed and the results are sad. So many of the one week old babies are getting fed 4-5 oz bottles (ughhh!) because it looks like they are just gulping it down.

I have one question. You say to angle the bottle nipple to the top of the mouth when the baby needs a break. Why not just slip it out of their mouth for a second and wait for baby to open his/her mouth if still hungry?

Removing the bottle to give them a break can be disorganizing for them. We don’t take the breast away to give them a break. If you remove the bottle, the baby doesn’t know that it’s close by if he wants more, and may not open his mouth if the edge has been taken off his hunger (but will be hungry again soon if he didn’t get a full feeding). Does that help to explain it? So glad to hear that you are teaching this to parents!

That’s true, we don’t take the breast out. What I usually say is to slip the bottle out of baby’s mouth and leave it right by the baby’s lips that way baby can smell it and feel the nipple there and if hungry he’ll open up again (like when initially latching baby on when breastfeeding). With the bottle nipple being longer, when angled up will it hit that spot on the roof of the mouth and stimulate the baby to suck even if not hungry?

THANK YOU for this!! Definitely one to save and pass around. I worked in a child care center caring for infants in college, obviously feeding many babies many bottles, and this is the first I’ve *ever* heard of any of this.

Hands down, this is the best advice I have read and I have read a lot of articles! I am breastfeeding my 2nd child and have also had to do loads of pumping. This has lots of suggestions for me and my baby’s care givers when I am away.

This gives great insight to the behaviors of babies and their cues/stresses to watch for. In thinking about it now, there absolutely IS a connection between how my baby nurses differently with me once she has been fed from a bottle.

I think it was one of the formula companies that actually told me to hold the baby at a 45degree angle, and the bottle at a 45degree angle to the baby, so that it’s nearly parallel to the floor… my daughter never liked more than 2-4oz (even at a year old she never went above 5oz!), but my son would still drink 4-6oz at only a couple weeks old (he also slept for 8-12 hours from the get go, nice!) Just to point out to the WIC agent that some babies actually are eating 4oz at a week, and that’s fine. I did this method not to limit how much they ate, but to combat upset tummies from eating too much too fast.

I NEVER knew about the ‘stressed out, too much milk!’ signal though! I’m definitely bookmarking this to help moms out there who ask me for bottlefeeding help.